MEDICARE: PRIME PHYSICAL THERAPY CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	25552	CA

General Provider Information

NPI Number	:	1497198410
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIME PHYSICAL THERAPY CORP

Provider Business Mailing Address
First Line	:	12832 GARDEN GROVE BLVD
Second Line	:	STE B
City	:	GARDEN GROVE
State	:	CA
Zip	:	92843-2002
Country	:	US
Telephone Number	:	714-620-8980
Fax Number	:	714-620-8982

Provider Business Practice Location Address
First Line	:	12832 GARDEN GROVE BLVD
Second Line	:	STE B
City	:	GARDEN GROVE
State	:	CA
Zip	:	92843-2002
Country	:	US
Telephone Number	:	714-620-8980
Fax Number	:	714-620-8982

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL D MAGA
Credential	:	MPT
Telephone Number	:	714-620-8980

Provider Enumeration Date	:	04/09/2013
Last Update Date	:	04/09/2013

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